Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Address: Sex: [M] [F] Age: Birth date: Height: Weight: Occupation: Hobby:

Size: px

Start display at page:

Download "Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Address: Sex: [M] [F] Age: Birth date: Height: Weight: Occupation: Hobby:"

Dina Smith
5 years ago
Views:

1 Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Address: Sex: [M] [F] Age: Birth date: Height: Weight: Marital Status: Single Married Widowed Separated Divorced Occupation: Hobby: Who may we thank for referring you? Current MD. Medical Prescriptions: Prior Surgeries: Has your doctor advised you to lose weight? Yes / No How much? lbs. Do you have any dietary restrictions? Yes / No Known Adverse Reactions to niacin or B vitamins? Yes / No Do you suspect you have a Thyroid Condition? Yes / No My energy on a 1-10 scale Low Very High How important is it for you to become healthy/lose weight? Do you experience? (Circle) Bloating, Reflux, Constipation, Diarrhea, Indigestion Please tell us your current health goals

2 What do you consider your ideal weight? When was the last time you were at your goal weight? How many times a year do you diet? What is stopping you from losing weight all on your own? Does your weight problem make you physically uncomfortable or cause pain? Yes / No Are you embarrassed by your excessive weight? Yes No Please explain: How much weight do you want to lose? Does being overweight and unhealthy limit your activities? Yes No Please explain: Do you binge eat? Yes No Do you suffer from uncontrollable cravings? Yes No Do you feel food controls you? Yes No Do you eat for emotional reasons (stress, anger, sadness, etc.)? Yes No Briefly describe your daily eating behavior: Do you feel your eating behavior is normal? Yes No How fast do you want to be slim, trim, and fit? What s more important to you fast or permanent? Is your family excited about you coming here for weight loss? Yes No Can you remember being your ideal weight? Yes No What do you remember most about it?

3 General Health Assessment Do you frequently feel tired? Does fatigue alter your lifestyle? Intestinal gas? Abdominal bloating? Crave sugar? Crave beer, wine or bread? Constipation or diarrhea? Irritable or easily angered? Faint, dizzy or lightheaded? Muscle aches? Weight gain? Loss of sexual desire? White or yellow fuzzy tongue? Athlete's foot, ringworm or jock itch? Fungus of toenails or fingernails? Bothered by perfumes/chemical smells? Ever take antibiotics? Using birth control (or have you)? On synthetic hormones? Itching or burning of vagina, rectum or prostate? Every taken steroids for allergies, asthma or injuries? Trouble thinking clearly and/or short term memory loss? Thyroid Function Assessment Do you have severe fatigue and find it hard to get up in the morning? Do you have generalized low energy? Do you need caffeine and/or other stimulants to get you going? Do you have a family history of thyroid disease? Do you gain weight easily? Have you had difficulty losing weight in the last 2 years? Do you have dry skin? Do you have constipation? Are your menstrual cycles irregular? Do you suffer from mood swings? Is your hair thinning? Is your hair dry/brittle? Do you have low sex drive?

4 Do you have high cholesterol? Do you have low blood pressure? Do you suffer from depression? Are the outer third of your eyebrows missing or thinning? Do you have any problems with remembering things? Stress Assessment/Adrenal Function Do you have a close support network of family and friends? Are you happy with your current job/profession? Do you consume caffeine, sugar or refined carbohydrates? Are you comfortable financially? Are you satisfied with your life and its direction? Do you keep your weight within normal range easily? Do you get 8 hours of uninterrupted sleep per night? Are you frequently anxious, depressed, or have panic attacks? Would you rate yourself as stressed? Do you have trouble falling asleep? Are you more tired after exercise? Toxic Burden Assessment How many fast food meals do you eat each week? None 1-2 meals 3 or more meals Do you consume 'diet foods' sweetened with aspartame, Splenda or saccharin? Do you tend to overeat? Do you regularly consume foods preserved with MSG (mono-sodium glutamate)? Do you eat foods that are artificially colored? Do you eat only organic produce? (Grown with no pesticides) How many different colors of vegetables & fruits do you eat in a day? Do you have an excessive consumption of sodas, coffee (two cups a day)? Do you drink 8-10 glasses of filtered, spring or mineral water every day? Do you experience GI distress? (gas, bloating, diarrhea, constipation) Do you consume alcohol? No Yes 1-4 / week Yes 5 or more/week Do you regularly use prescription or over the counter (OTC) medication? How many hours a day do you spend in front of a computer? < > Just curious, which is the most important for you? (Please circle ONE) EFFECTIVENESS My results are my top priority TIME I want results quickly SERVICE I will need extra support along the way AFFORDABILITY Cost is my major concern

5 Have you had ANY of the following? (C for current X for in last 12 months) GENERAL-Pregnant Pacemaker Cancer Hyperthyroid Hypothyroid Epilepsy Dizziness Fainting Fatigue Fever Headache Loss of Sleep Allergy (to what ) Loss of Weight Nervousness Wheezing Bronchitis Numbness in BOTH hands AND feet Currently Undergoing Chemotherapy CARDIOVASCULAR Blood Thinners High Blood Pressure Low Blood Pressure Heart Disease Poor Circulation Rapid Heartbeat Previous Heart Problem (Describe ) Slow Heartbeat Stroke TIA Swollen Ankles Varicose Veins Aortic Aneurysm Bruise Easily DISEASES/CONDITIONS Appendicitis Anemia Arthritis Alcoholism Bleeding Disorder Blood Clot(s) Breathing Difficulty Cancer Cholesterol High Colon Problems Diabetes Depression Eczema Eating Disorder Glaucoma HIV + Heart Disease Kidney Disease Liver Disease Mental Illness Prostate Problems Hyperthyroid Hypothyroid Rectal Surgery EARS/EYES/NOSE/THROAT Asthma Crossed Eyes Double Vision Blurred Vision Difficulty Swallowing Deafness Hearing Loss Ear Pain Thyroid Problem Nose Bleeds Sinus Problems Sore Throats GASTRO-INTESTINAL Gas Colon Trouble Constipation Diarrhea Gallbladder Trouble Hemorrhoids Liver Trouble Nausea Stomach Ache Poor Appetite Poor Digestion Vomiting Rectal Bleeding Bloating GENITO-URINARY Blood in Urine Frequent Urination Inability to control urine Kidney Infection Painful Urination FOR MEN ONLY Lump in testicles Penis discharge FOR WOMEN ONLY Currently Pregnant Breast Feeding Menstrual Cramps Excessive menstrual flow Hot Flashes Irregular Cycle Painful periods Birth Control Pills Abnormal Pap Smear MUSCLE/JOINT/BONE Backache Foot Trouble Pain Between Shoulders Painful Tailbone Stiff Neck Spinal Curvature Swollen Joints Low Back Pain NEUROLOGIC Seizures Dizziness Hand Trembling Weakness Loss of memory Loss of coordination RESPIRATORY Chest Pain Chronic Cough Difficulty Breathing

6 Consent Form (The Not So Fine Print) The Health Part As you can imagine, results on a program of this nature vary and cannot be guaranteed. Recommended supplements, herbs, etc. are intended to work with specific diet/lifestyle changes, which are a critical part of the process. (So no cheating!) In general, you will get out of it what you put in. All supplements, vitamins, herbs recommended are generally considered safe, however, some can interact with certain medications, so please consult with your prescribing physician before beginning program. If currently taking medications, please don't stop without consulting with your doctor. If you have a high/low blood pressure or sugar, please monitor it carefully because as your health improves, you may need to speak with your doctor about adjusting medications accordingly. Every precaution is taken to ensure safety. Our programs and supplements have helped thousands achieve their goals, however, we cannot predict how each person will respond to each supplement (allergies, etc.). Therefore, you are acting at your own risk. Please advise us and your doctor if necessary, if you experience any unpleasant or unanticipated side effects including gastrointestinal upset, allergic reactions, etc. We do not diagnose or treat diseases including but not limited to diabetes, heart disease, cancer, autoimmune, thyroid disease, etc. We treat people. Your signature indicates that you authorize the staff to perform any necessary services, and that the above information was completed correctly to the best of your knowledge. It is your responsibility to inform this office of any changes to the information you have provided. The Unavoidable Money Part Your signature below indicates that you understand that you are solely responsible for any treatment rendered in this office. We cannot accept insurance for detox, cleansing, or weight loss services. The Most Important Part Ultimately, great communication is the key to any great, long lasting relationship. If something is on your mind, from symptoms you experience to ways we can improve our services, please let us know! You can reach Dr. Infantino directly on his cell number to share a win, make a suggestion or just to give him feedback. We truly look forward to serving you. Welcome to our family! Signature

7 How we protect your Health Information: PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR HEALTHCARE PURPOSES By signing this Consent, I acknowledge and provide permission to Platinum Wellness (Practice) as follows: 1. Platinum s Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information ( PHI ) necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out is health care operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Con-sent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent. 2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. 3. I understand that, and consent to, the following appointment reminders that will be used by the Practice: a) A postcard mailed to me at the address provided by me; and b) telephoning my home and leaving message on my answering machine or with the individual answering the phone. 4.The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations. 5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice. 6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent. 7. I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me. 8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice reserves the right to not treat me. I have read and understand the health information disclosure and protection in the foregoing notice. PRINTED Name SIGNATURE DATE Signature of Legal Guardian (e.g. if a minor) Relationship to minor

Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Address: Sex: M F Age: Birth date: Height: Weight: Occupation: Hobby:

Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Sex: M F Age: Birth date: Height: Weight: Marital Status: Single Married Widowed Separated Divorced Occupation: Hobby: